Provider Demographics
NPI:1285674499
Name:BROEREN, SANDRA CAROL (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:CAROL
Last Name:BROEREN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17055 RUBEN LN
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:OR
Mailing Address - Zip Code:97055-9276
Mailing Address - Country:US
Mailing Address - Phone:503-668-8002
Mailing Address - Fax:503-668-5246
Practice Address - Street 1:17055 RUBEN LN
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:OR
Practice Address - Zip Code:97055-9276
Practice Address - Country:US
Practice Address - Phone:503-668-8002
Practice Address - Fax:503-668-5246
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL26866207R00000X
ORMD157517207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009933006Medicaid
AL051529785OtherBLUE CROSS
AL009933004Medicaid
AL009933007Medicaid
AL051529786OtherBLUE CROSS
AL009933008Medicaid
AL051529784OtherBLUE CROSS
AL051529787OtherBLUE CROSS
AL009933007Medicaid